Comparison of the Effects of Quality Improvement Strategies on Prevention of Mother-to-Child HIV Transmission in a Public and a Private Hospital in Lesotho.

We compared quality improvement (QI) interventions for prevention of mother-to-child transmission in a private hospital and a government hospital (GH). From November 2013 to October 2016, data were extracted retrospectively for HIV-positive mothers and HIV-exposed infants. The overall number of mother-baby pairs (MBPs) was significantly (P < .001) higher at the GH (mean = 294, standard deviation [SD] = 180) than the private hospital (mean = 72, SD = 27). There was a significantly higher number of MBPs receiving care (P < .001) and routine services (P < .001) at the GH. The proportion of MBPs retained in care (P < .001) and receiving the routine service package (P < .001) was significantly higher at the private hospital. Overtime, indicators at the private hospital peaked significantly in year 2 and reduced moderately in the final year. The trend for the GH showed gradual but nonsignificant improvement in 2 indicators. QI showed positive results in the private hospital. If systematically applied in GHs, QI can support improved services for larger patient volumes.

Applying Quality Improvement Strategies to Health Services for HIV-Affected Mother-Baby Pairs in Rural Kenya.

The Partnership for HIV-Free Survival (PHFS) was piloted in rural Kenya using a quality improvement approach to integrate nutrition with prevention of mother-to-child transmission (PMTCT) of HIV services. Data were collected in a preintervention baseline (January 2013 to August 2013) and 3 periods during implementation (September 2013 to June 2016). Integration of nutrition assessment, counseling, and support (NACS) in PMTCT and retention of mother-baby pairs (MBPs) in care showed significant increase over time: The MBPs receiving NACS increased from a baseline median of 15% to 88% (P ≤ .05), and the proportion of MBPs retained in active care increased from a baseline median of 19% to a median of 66% (P ≤ .01). Declines observed in the number of HIV-exposed infants who tested positive for HIV at 18 months were not statistically significant. The PHFS was successful in integrating NACS into PMTCT services and increasing retention of MBPs in care in Kenya.

Increasing HIV-Free Survival of Infants: Reorganizing Care Using Quality Improvement for the Optimal Health and Nutrition of HIV-Positive Women and Their Exposed Infants in Uganda.

Reorganizing service delivery to integrate nutrition and infant and young child feeding (IYCF) with prevention of mother-to-child transmission (PMTCT) is important for improving outcomes of HIV-positive mothers and HIV-exposed infants (HEIs). Quality improvement (QI) strategies were implemented at 22 health facilities. The percentage of HIV-positive pregnant women and lactating mothers who received IYCF counseling at each visit improved (45%-100%; mean = 93.1%, standard deviation [SD] = 15.5). Adherence to IYCF practices improved (70%-96%; mean = 92.4%, SD = 8.5). Mother-baby pairs receiving the standard care package improved (0%-100%; mean = 98.6%, SD = 22.6). The HEIs alive at 18 months and infected decreased (mean = 6.2%, SD = 4.8). Statistical significance of change was estimated using Fisher exact test and magnitude of change over time by calculating the odds ratio. For all indicators, improvement was rapid and significant (P < .001), especially in the first 6 months of QI implementation. Using QI to integrate nutrition and ensure consistent and comprehensive PMTCT service delivery improved IYCF adherence and decreased transmission.

Awareness and Attitudes of Research Students Toward Dual-use Research of Concern in Pakistan: A Cross-sectional Questionnaire.

Dual-use research poses a significant challenge for scientists in the biomedical field and for global health security in general. As the scientific knowledge and materials required for the development of biological agents become progressively more accessible and inexpensive, there is an increased need to understand and improve the governance of scientific research. Prevention of the misuse of facilities, equipment, agents, and scientific knowledge requires high levels of awareness of the concept of dual-use research, starting with early-career scientists and graduate students. In this study, the attitudes and level of awareness of postgraduate students in Pakistan toward the issues surrounding dual-use research were assessed through a survey containing both quantitative and qualitative questions in 32 universities in 4 provinces, federal area, and Azad Jammu and Kashmir regions of Pakistan; 933 students responded. Most (58.2%) had never heard of dual-use research of concern (DURC), while 18.5% had heard the term but were unsure of its meaning. Irrespective of prior knowledge, a higher percentage of students (68.6%) felt an obligation to report research misuse. Considering the need for DURC training, 94.1% of the respondents agreed that the principal investigator should take the responsibility to train students on DURC at the start of a research project. When experimental results having dual-use potential, 69.1% indicated they would publish with limited protocol, with 43.5% indicating they would publish the limited protocol only if there was a way for scientists to access their data. The survey results revealed limited DURC awareness among researchers across Pakistan. However, the respondents, although not formally educated about DURC, were quite aware of its impact. The information gained in this survey will be valuable in addressing country-specific awareness and training needs.

Engagement of National Stakeholders and Communities on Health-Care Quality Improvement: Experience from the Implementation of the Partnership for HIV-Free Survival in Tanzania.

The Partnership for HIV-Free Survival initiative in Tanzania integrated postnatal nutrition and mother-to-child transmission (MTCT) cascades to reduce vertical HIV transmission. Quality improvement (QI) was implemented in 30 health facilities. Net positive gain resulted in overall improvement in all indicators (above 80%) by the end of the reporting period. Retention in postnatal care (mean = 49.8, standard deviation [SD] = 27.6) and in monthly HIV services (mean = 65.4, SD = 29.5) had the lowest average but showed consecutive and significant (P ≤ .001) gains except for significant decreases in 1 of 6 periods assessed. Average antiretroviral therapy uptake among women (mean = 81.7, SD = 29.5) was highest, with an initial positive gain of 78.9% (P ≤ .001). DNA/polymerase chain reaction for HIV-exposed infants (mean = 71.8, SD = 20.9) and nutrition counseling (mean = 71.2, SD = 26.3) showed similar average performance, with the latter being the only indicator with significant equal periods of gain and decreases. The collaborative QI approach improved process indicators for reducing MTCT in resource-constrained health systems.

Bridging the gap between clinical practice and public health: Using EHR data to assess trends in the seasonality of blood-pressure control.

Electronic health records (EHRs) provide timely access to millions of patient data records while limiting errors associated with manual data extraction. To demonstrate these advantages of EHRs to public health practice, we examine the ability of a EHR calculated blood-pressure (BP) measure to replicate seasonal variation as reported by prior studies that used manual data extraction. Our sample included 609 primary-care practices in New York City. BP control among hypertensives was defined as systolic blood pressure of 140 or less and diastolic blood pressure of 90 or less (BP < 140/90 mm Hg). An innovative query-distribution system was used to extract monthly BP control values from the EHRs of adult patients diagnosed with hypertension over a 25-month period. Generalized estimating equations were used to compare the association between seasonal temperature variations and BP control rates at the practice level, while adjusting for known demographic factors (age, gender), comorbid diseases (diabetes) associated with blood pressure, and months since EHR implementation. BP control rates increased gradually from the spring months to peak summer months before declining in the fall months. In addition to seasonal variation, the adjusted model showed that a 1% increase in patients with a diabetic comorbidity is associated with an increase of 3% (OR 1.03; CI 1.028-1.032) on the BP measure. Our findings identified cyclic trends in BP control and highlighted greater association with increased proportion of diabetic patients, therefore confirming the ability of the EHR as a tool for measuring population health outcomes.

Secondary Infections with Ebola Virus in Rural Communities, Liberia and Guinea, 2014-2015.

Persons who died of Ebola virus disease at home in rural communities in Liberia and Guinea resulted in more secondary infections than persons admitted to Ebola treatment units. Intensified monitoring of contacts of persons who died of this disease in the community is an evidence-based approach to reduce virus transmission in rural communities.

Findings from a pilot environmental health intervention at early childhood centers in the District of Columbia.

BACKGROUND: Children are uniquely susceptible to environmental health exposures that effect developmental delays and negatively impact long-term health outcomes. Despite extensive hours spent at early child care centers, child care providers (CCPs) lack the knowledge to identify and mitigate environmental hazards to the children. METHODS: From 2007 to 2010, we recruited child care centers in the District of Columbia and offered interactive environmental health training to the CCPs. Each center underwent a 90-min environmental health risk assessment (ERA) at baseline and also after the trainings. Dependent t-tests were used to assess the mean change on the ERA score and also the knowledge test administered pre- and post-trainings. Analysis of variance was used to examine the association between knowledge change for the CCPs and the ERA scores of their centers. RESULTS: Of the 60 facilities, 68% reduced their environmental risk. The 585 CCPs who attended the training session showed significant improvement on all items on the test. However, test scores for the CCPs from centers that reduced their risk were not significantly different from the other CCPs. CONCLUSIONS: The trainings increased knowledge on environmental health hazards among CCPs. Areas of significant risk reduction were under the direct control of the CCPs and corresponded to key items on the knowledge test.

Applied Use of Composite Quality Measures for EHR-enabled Practices.

INTRODUCTION: The Primary Care Information Project (PCIP) of the New York City Department of Health and Mental Hygiene has been assisting providers to implement health information technology such as electronic health records (EHRs) since its founding in 2005. Currently, all practices affiliated with PCIP are offered technical support services in order to improve the use of the EHR. We studied the performance of clinical practices on EHR-derived Composite Quality Measures (CQMs) over time. Because specific EHR functionalities are important to calculating the quality measures, we hypothesize that performance on each of the CQMs will differ according to the EHR functionalities, and that this can inform the process of developing targeted technical assistance for the practices. METHODS: We created four CQMs: (1) Screening, (2) Assessment, (3) Control-BP, and (4) Control-Other. Using data from 93 practices, we identified three tertiles of CQM performance (premier, average, and low tiers) for each measure. A scatterplot of CQMs in 2010 versus 2011 was used to examine the individual movement of practices by tier. A dependent t-test compared the change in mean CQMs, and a chi-square test examined the association between the score and performance tier changes. RESULTS: Over a one-year period, low tier practices demonstrated the highest gains, average tier practices had modest gains, and premier tier practices had gains in some measures, but losses in others. On the Screening CQM 70 percent of practices remained within the same tier, with 60 percent on Assessment, 52 percent on Control-BP, and 38 percent on Control-Other; the Control-Other group showed the greatest improvement. DISCUSSION: By considering EHR functionalities associated with each of the four CQMs, we suggest that technical assistance can be better targeted to low-tier performing practices. In addition, there is still the potential for improvement over time at practices more familiar with key functionalities.

Developing Composite Quality Measures for EHR-Enabled Primary Care Practices in New York City.

We describe the process of developing composite quality measures (CQMs). During the initial consultative process, we grouped quality measures based on the associated clinical workflow and difficulty, and then confirmed the groupings with factor analysis. The CQMs are estimated as the mean of the measures for each group. We used analysis of variance followed by a post hoc analysis to assess: (1) performance among the different CQMs each year; and (2) the performance trend for each of the composite measures from 2009 to 2011. The four CQMs were Control-BP, Control-Other, Assessment, and Screening. Performance was highest at baseline for Control-BP (58%, SD 15.07), followed by Control-Other (48.04%, SD 22.75), Screening (46.49%, SD 20.21), and Assessment (42.15%, SD 19.08). Performance on the CQMs increased significantly with time, whereas the gap between the CQMs decreased significantly over time. The CQMs reflect the clinical care domains, and practice performance is influenced by electronic health record functionality, clinician workflow, and clinical difficulty.